VERIFICATION OF K-12 EDUCATOR EXPERIENCE

last name first name middle name maiden name

Molina Clara Inés      

street address city state zip code

304 Winston Lane Windsor NC 27983

social security number email address

claram229@hotmail.com

 To the employer: Please return this form to the employee. Do not send it directly to the Licensure Section.

Box A Professional Educator (K-12) Experience (to be completed by employer)

School system Total hours
Beginning date of Position title (e.g., teacher,
Ending date of service worked per week
service counselor, supervisor,
Public Private (month, day, year) full-time
(month, day, year) principal, superintendent)
part-time
Gimnasio Los Farallones Valle 09.01.07 06.30.08 40 Teacher
del lily
09.01.09 06.30.10 40 Teacher
09.01.10 06.30.11 40 Teacher
09.01.11 06.30.12 40 Teacher
09.01.12 06.30.13 40 Teacher

Box B K-12 Instructional Teacher Assistant Experience (to be completed by employer)

School system Beginning date Ending date Total hours IMPORTANT:
of service of service worked per Check one box below for each
(month, day, year) (month, day, year) week assignment.
The assignment meets the criteria
Please use a separate line for each school year.
statement* below.
Yes No
Yes No
Yes No
Yes No
Yes No

*CRITERIA STATEMENT:
The instructional teaching assistant assignment listed above was service in the classroom with school-age
children with actual instructional teaching responsibilities comprising a minimum of 50% of daily activities.

I certify that this verification omits leave of absence periods and that all information is complete
and correct according to the official records of this school system.

signature of superintendent or designee date telephone address

title email address city, state, and zip code

Public Schools of North Carolina

Department of Public Instruction
Licensure Section Form E
August 2016
 Experience Credit: How to Apply

For experience as a professional educator:

Have Form E (Verification of Experience) completed by your former employer(s). If you are submitting
experience from more than one employer, have each one complete a separate form. Form E may be
copied as needed. Please note that only experience of one-half time or more (fifteen hours per week) will
be considered in the evaluation.

 Experience as a K-12 professional educator (teacher, counselor, principal, etc.) should be

reported in Box A. All requested information must be supplied. Beginning and ending dates
must include month, day, and year.

 Experience as a K-12 instructional teacher assistant should be reported in Box B. All

requested information must be supplied. Beginning and ending dates must include month, day,
and year. Employers must indicate whether or not each year of experience meets the criteria
for credit by checking the appropriate box in the right hand column.

Submitting Form E

 Upload a completed and signed copy of Form E at

https://vo.licensure.ncpublicschools.gov/. Application instructions and additional information
are available within the online licensure system.

Note: Non-teaching Work Experience cannot be requested using this form. Requests for
Non-teaching Work Experience must be submitted online using Form NE, along with
additional documentation from the personnel office of the employing NC school
system.

Public Schools of North Carolina

Department of Public Instruction Form E
Licensure Section August 2016